1986, 03-14 Permit App: 00010361 Plumbing Fixtures PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# fe
Owner's Name .,ev4 Last First MI
Project Address(Street NT Nurrt , A '
....5-yr ��,Q
City g State ���� Subdivision/Plat Name
Assessors 'a # Lot Block Plat#
Applicant Address
City I State Zip Phone
)Business Phone
Contractor ® /�f
c�Qpess `5j� / 19
/`moi , , //]y/ f/C G/L,,,,„„:„ ,
,„City State Zip Phone
ZOS
Contact Lic nse# ” Busin Phone
, 41 ceo 4dam/hl
Describe Work
Oirr Sky:- /1315i6d
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s): j
Deh Wshr(s): Garb Disp(s): Kit Sink(s): Lndry Tray(s): Sew Eject(s): /
edr
Urinal(s): Wtr Closet(s): Lav(s): Shower : Tub(s): ,
cs) s c ) cs) ( cs> c)
Bidets:
3 L,
W
Other: Type;
CC
n
X Waste/Grease Interceptor(s):
U-
W Sewer V N Septic/Health No.:
O
M
W
COElectric Water Heater(s): / Drains-Roof:
D
Z REPAIR OR ALTERATION: Drainage,Vent,Water Piping/Treatment: Y N
Lawn Sprinkler System(s),including backflow device on any one meter:
Vacuum breakers or backflow devices in excess of line 16:1-5: I (Or)5+:
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this type of work, including inspection requirements, will be com-
plied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state of local laws regulating construction or the performance of
construction.
\,
SIGNATURE O ,1 �-!�� t� APPLICATION 1� ,�
AWNER OR AGEN .� DATE 1”` �"